Margaret Jones

Introduction This is the fourth phase of a longitudinal cohort study (2022–2023) to investigate the health and well-being of UK serving (Regulars and Reservists) and ex-serving personnel (veterans) who served during the era of the Iraq and Afghanistan conflicts. The cohort was established in 2003 and has collected data over three previous phases including Phase 1 (2004–2006), Phase 2 (2007–2009) and Phase 3 (2014–2016). Methods and analysis Participants are eligible to take part if they completed the King’s Centre for Military Health Research Health and Wellbeing Cohort Study at Phase 3 (2014–2016) and consented to be recontacted (N=7608). Participants will be recruited through email, post and text message to complete an online or paper questionnaire. Data are being collected between January 2022 and September 2023. Health and well-being measures include measures used in previous phases that assess common mental disorders, post-traumatic stress disorder (PTSD) and alcohol misuse. Other areas of interest assess employment, help-seeking and family relationships. New topics include the impact of the British withdrawal from Afghanistan in 2021, complex PTSD (C-PTSD), illicit drug use, gambling and loneliness. Analyses will describe the effect size between groups deployed to Iraq and/or Afghanistan or not deployed, and those who are currently in service versus ex-service personnel, respectively, reporting prevalences with 95% CIs, and ORs with 95% CI. Multivariable logistic and multiple linear regression analyses will be conducted to assess various health and well-being outcomes and associations with risk and protective factors. Ethics and dissemination Ethical approval has been granted by the Ministry of Defence Research Ethics Committee (Ref: 2061/MODREC/21). Participants are provided with information and agree to a series of consent statements before taking part. Findings will be disseminated to UK Armed Forces stakeholders and international research institutions through stakeholder meetings, project reports and scientific publications.

Introduction: This is the fourth phase of a longitudinal cohort study (2022-2023) to investigate the health and wellbeing of UK serving (Regulars and Reservists) and ex-serving personnel (veterans) who served during the era of the Iraq and Afghanistan conflicts. The cohort study was established in 2003 and has collected data over three previous phases including Phase 1 (2004-2006), Phase 2 (2007-2009) and Phase 3 (2014-2016). Methods and analysis: Participants are eligible to take part if they completed the King’s Centre for Military Health Research (KCMHR) Health and Wellbeing Cohort Study at Phase 3 (2014-2016) and consented to be recontacted. Participants meeting these criteria will be recruited through email, post, and text message to complete an online or paper questionnaire. The study provides a fourth phase of quantitative longitudinal data on this cohort. Data are being collected between January 2022 and September 2023. Health and wellbeing measures used in Phase 4 include measures used in previous phases that assess common mental disorders (CMD), post-traumatic stress disorder (PTSD) and alcohol misuse. Other areas of interest assess multiple symptom illness, employment, help-seeking, and family relationships. New topics include the impact of the British withdrawal from Afghanistan in 2021, Complex-PTSD (C-PTSD), illicit drug use, gambling, and loneliness. The main analyses will compare mental health status according to deployment experiences and serving status (serving or ex-service) reporting prevalences with 95% Confidence Intervals (CI), and Odds Ratios (ORs) with 95% CI. Analyses will describe the effect size between groups deployed to Iraq and/or Afghanistan or not deployed, and those who are currently in service versus ex-service personnel respectively. Multivariable logistic and multiple linear regression analyses will be conducted to assess various health and wellbeing outcomes and associations with risk and protective factors, adjusting for potential confounders. Ethics and dissemination: Ethical approval has been granted by the Ministry of Defence Research Ethics Committee (Ref: 2061/MODREC/21). Participants are provided with information and agree to a series of consent statements before taking part. Data are kept on secure servers and in locked cabinets/offices, with access to personally identifiable information limited. Findings will be disseminated to UK Armed Forces stakeholders and international research institutions through stakeholder meetings, project reports and scientific publications. Strengths and limitations of this study: Strengths of this study include the original cohort recruitment from a random, representative sample of UK service personnel. Strengths also include recruitment from a cohort where underlying characteristics are known and longitudinal data are held on their health and wellbeing. The study has maintained validated and harmonised health and wellbeing measures across phases, whilst including new areas relevant to the cohort’s current experiences. This study will provide continued longitudinal data on this Armed Forces cohort. Study limitations include recruitment from a specific cohort; hence the study cannot comment on older era cohorts or those who joined the Armed Forces more recently.

Objectives Excessive alcohol use can bring about adverse health and work-related consequences in civilian and military populations. Screening for excessive drinking can help identify individuals at risk for alcohol-related problems who may require clinical interventions. The brief validated measures of alcohol use such as the Alcohol Use Disorders Identification Test (AUDIT), or abbreviated AUDIT-Consumption (AUDIT-C), are often included in military deployment screening and epidemiologic surveys, but appropriate cut-points must be used to effectively identify individuals at risk. Although the conventional AUDIT-C cut-points ≥4 for men and ≥3 for women are commonly used, recent validation studies of veterans and civilians recommend higher cut-points to minimise misclassification and overestimation of alcohol-related problems. This study aims to ascertain optimal AUDIT-C cut-points for detecting alcohol-related problems among serving Canadian, UK and US soldiers. Design Cross-sectional pre/post-deployment survey data were used. Settings Comprised Army locations in Canada and UK, and selected US Army units. Participants Included soldiers in each of the above-mentioned settings. Outcome measures Soldiers’ AUDIT scores for hazardous and harmful alcohol use or high levels of alcohol problems served as a benchmark against which optimal sex-specific AUDIT-C cut-points were assessed. Results Across the three-nation samples, AUDIT-C cut-points of ≥6/7 for men and ≥5/6 for women performed well in detecting hazardous and harmful alcohol use and provided comparable prevalence estimates to AUDIT scores ≥8 for men and ≥7 for women. The AUDIT-C cut-point ≥8/9 for both men and women performed fair-to-good when benchmarked against AUDIT ≥16, although inflated AUDIT-C-derived prevalence estimates and low positive predictive values were observed. Conclusion This multi-national study provides valuable information regarding appropriate AUDIT-C cut-points for detecting hazardous and harmful alcohol use, and high levels of alcohol problems among soldiers. Such information can be useful for population surveillance, pre-deployment/post-deployment screening of military personnel, and clinical practice.

Purpose: Risk of violence by UK military personnel, both towards non-family and family, has been found to be higher post-deployment. However, no UK research to date has attempted to examine relationship conflict and intimate partner violence (IPV) in this period. This study estimated the prevalence of and risk factors for post-deployment relationship conflict and partner violence in UK military personnel. Methods: We utilised data on military personnel who had deployed to Iraq and/or Afghanistan (n = 5437), drawn from a large cohort study into the health and well-being of UK military personnel. Results: 34.7% reported relationship conflict (arguing with partner) and 3.4% reported perpetrating physical IPV post-deployment. Males were more likely than females to report relationship conflict. There were similar rates of self-reported physical IPV perpetration among males and females. Among our male sample, factors associated with both relationship conflict and physical IPV perpetration post-deployment included being in the Army compared with the Royal Air Force, higher levels of childhood adversity, higher levels of military trauma exposure and recent mental health and alcohol misuse problems. Being over 40 at time of deployment (vs being under 25) and having deployed in a combat role were also associated with relationship conflict, but not physical IPV perpetration. Conclusions: Deployment-related variables and mental health and alcohol misuse problems were found to be key factors associated with post-deployment relationship conflict and IPV. Services providing health or welfare support to military personnel must collaborate with mental health services and consider history of deployment, and particularly deployment-related trauma, in their assessments to improve identification and management of intimate partner violence and abuse in military communities.

Introduction The UK is the only permanent member of the UN Security Council that has a policy of recruiting 16 and 17 year old individuals into its regular Armed Forces. Little is known about the consequences of enlisting as a Junior Entrant (JE), although concerns have been expressed. We compare the mental health, deployment history, and pre-enlistment and post-enlistment experiences of personnel who had enlisted as JEs with personnel who joined as Standard Entrants (SEs). Method Participants from a large UK military cohort study completed a self-report questionnaire between 2014 and 2016 that included symptoms of probable post-traumatic stress disorder (PTSD), common mental disorders, alcohol consumption, physical symptoms and lifetime self-harm. Data from regular non-officer participants (n=4447) from all service branches were used in the analysis. JEs were defined as having enlisted before the age of 17.5 years. A subgroup analysis of participants who had joined or commenced adult service after April 2003 was carried out. Results JEs were not more likely to deploy to Iraq or Afghanistan but were more likely to hold a combat role when they did (OR 1.25, 95% CI 1.00 to 1.56). There was no evidence of an increase in symptoms of common mental disorders, PTSD, multiple somatic symptoms (MSS), alcohol misuse or self-harm in JEs in the full sample, but there was an increase in alcohol misuse (OR 1.84, 95% CI 1.18 to 2.87), MSS (OR 1.51, 95% CI 1.04 to 2.20) and self-harm (OR 2.13, 95% CI 1.15 to 3.95) in JEs who had commenced adult service after April 2003. JEs remain in adult service for longer and do not have more difficulties when they leave service. Conclusions JEs do not have worse mental health than SEs, but there is uncertainty in relation to alcohol misuse, MSS and self-harm in more recent joiners. Monitoring these concerns is advisable.

Introduction We will use a sub-sample of a current longitudinal study to investigate the impact of COVID-19 on the health and wellbeing of ex-service personnel in the UK. The study will provide evidence for the UK Office of Veterans’ Affairs (OVA), UK stakeholders supporting the ex-service community, and evidence to inform our international counterparts working with ex-service communities in allied countries regarding the impact of COVID-19 on the health and wellbeing of ex-service personnel. Methods and analysis Participants were eligible to participate if they lived in the UK, had Regular service history from the UK Armed Forces and had previously completed the King’s Centre for Military Health Research (KCMHR) Health and Wellbeing survey between 2014–2016. Participants who met these criteria were recruited through email to take part in an online questionnaire. The study provides additional quantitative longitudinal data on this sub-sample. Data are being collected June 2020-September 2020. Specific measures are used to capture participants’ COVID-19 experiences, health and wellbeing status and lifestyle behaviours. Other key topics will include questions regarding the impact of COVID-19 pandemic on employment, finances, volunteering, charitable giving, accommodation and living arrangements, help-seeking behaviours, as well as any potential positive changes during this period. Ethics and Dissemination Ethical approval has been gained from King’s College London Research Ethics Committee (Ref: HR-19/20–18626). Participants were provided with information and agreed to a series of consent statements before enrolment. Data are kept on secure servers with access to personally identifiable information limited. Findings will be disseminated to the OVA, UK ex-service stakeholders and international research institutions through stakeholder meetings, project reports and scientific publications. Strengths and limitations of this study Strengths include recruitment from a population where underlying characteristics are known, and longitudinal data is held on their health and wellbeing. There has been rapid roll-out of the survey to ensure relevance for participants’ COVID-19 experiences and use of validated measures for mental health and wellbeing outcomes. Study limitations include recruitment from a specific cohort; hence the study cannot comment on the impact of COVID-19 in other veteran populations.

Background: A proportion of ex-military personnel who develop mental health and social problems end up in the Criminal Justice System. A government review called for better understanding of pathways to offending among ex-military personnel to improve services and reduce reoffending. We utilised data linkage with criminal records to examine the patterns of offending among military personnel after they leave service and the associated risk (including mental health and alcohol problems) and socio-economic protective factors.Method: Questionnaire data from a cohort study of 13 856 randomly selected UK military personnel were linked with national criminal records to examine changes in the rates of offending after leaving service.Results: All types of offending increased after leaving service, with violent offending being the most prevalent. Offending was predicted by mental health and alcohol problems: probable PTSD, symptoms of common mental disorder and aggressive behaviour (verbal, property and threatened or actual physical aggression). Reduced risk of offending was associated with post-service socio-economic factors: absence of debt, stable housing and relationship satisfaction. These factors were associated with a reduced risk of offending in the presence of mental health risk factors.Conclusions: Ex-military personnel are more likely to commit violent offences after leaving service than other offence-types. Mental health and alcohol problems are associated with increased risk of post-service offending, and socio-economic stability is associated with reduced risk of offending among military veterans with these problems. Efforts to reduce post-service offending should encompass management of socio-economic risk factors as well as mental health.

Background: UK armed forces personnel are at risk of occupational psychological injury; they are often reluctant to seek help for such problems. Objective: We aimed to examine and describe sources of support, prevalence and associates of help-seeking among UK serving and ex-serving personnel. Method: A total of 1450 participants who self-reported a stress, emotional or mental health problem in the past 3 years were sampled from a health and wellbeing study and subsequently completed a telephone interview comprising measures of mental disorder symptoms, alcohol misuse and help-seeking behaviour. Results: Seven per cent of participants had not sought any help, 55% had accessed medical sources of support (general practitioner or mental health specialist), 46% had received formal non-medical (welfare) support and 86% had used informal support. Gender, age, perceived health, functional impairment, social support, deployment, alcohol and comorbidity impacted upon the choice of help source. Conclusions: This study found that the majority of those with perceived mental health problems sought some form of help, with over half using formal medical sources of support. • In contrast to previous studies of help-seeking in serving and ex-serving personnel, and the public perception, this study found that the majority of those with perceived mental health problems sought some form of help.• Over half used formal medical sources of support.• Younger males who reported lower levels of social support were less likely to seek support.

Background: Little is known about the prevalence of mental health outcomes in UK personnel at the end of the British involvement in the Iraq and Afghanistan conflicts.Aims: We examined the prevalence of mental disorders and alcohol misuse, whether this differed between serving and ex-serving regular personnel and by deployment status.Method: This is the third phase of a military cohort study (2014–2016; n = 8093). The sample was based on participants from previous phases (2004–2006 and 2007–2009) and a new randomly selected sample of those who had joined the UK armed forces since 2009.Results: The prevalence was 6.2% for probable post-traumatic stress disorder, 21.9% for common mental disorders and 10.0% for alcohol misuse. Deployment to Iraq or Afghanistan and a combat role during deployment were associated with significantly worse mental health outcomes and alcohol misuse in ex-serving regular personnel but not in currently serving regular personnel.Conclusions: The findings highlight an increasing prevalence of post-traumatic stress disorder and a lowering prevalence of alcohol misuse compared with our previous findings and stresses the importance of continued surveillance during service and beyond.Declaration of interest: All authors are based at King's College London which, for the purpose of this study and other military-related studies, receives funding from the UK Ministry of Defence (MoD). S.A.M.S., M.J., L.H., D.P., S.M. and R.J.R. salaries were totally or partially paid by the UK MoD. The UK MoD provides support to the Academic Department of Military Mental Health, and the salaries of N.J., N.G. and N.T.F. are covered totally or partly by this contribution. D.Mu. is employed by Combat Stress, a national UK charity that provides clinical mental health services to veterans. D.MacM. is the lead consultant for an NHS Veteran Mental Health Service. N.G. is the Royal College of Psychiatrists’ Lead for Military and Veterans’ Health, a trustee of Walking with the Wounded, and an independent director at the Forces in Mind Trust; however, he was not directed by these organisations in any way in relation to his contribution to this paper. N.J. is a full-time member of the armed forces seconded to King's College London. N.T.F. reports grants from the US Department of Defense and the UK MoD, is a trustee (unpaid) of The Warrior Programme and an independent advisor to the Independent Group Advising on the Release of Data (IGARD). S.W. is a trustee (unpaid) of Combat Stress and Honorary Civilian Consultant Advisor in Psychiatry for the British Army (unpaid). S.W. is affiliated to the National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Emergency Preparedness and Response at King's College London in partnership with Public Health England, in collaboration with the University of East Anglia and Newcastle University. The views expressed are those of the author(s) and not necessarily those of the National Health Service, the NIHR, the Department of Health, Public Health England or the UK MoD.